Provider Demographics
NPI:1487129789
Name:LONG, ANNA MARIE (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:MARIE
Other - Last Name:OGLESBEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LD
Mailing Address - Street 1:9525 N CAPITAL OF TEXAS HWY UNIT 212
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-7292
Mailing Address - Country:US
Mailing Address - Phone:903-390-6709
Mailing Address - Fax:
Practice Address - Street 1:2520 LONGVIEW ST STE 307
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-4202
Practice Address - Country:US
Practice Address - Phone:512-815-3438
Practice Address - Fax:512-205-3455
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85673133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered